Bariatric Surgery

We perform three types of bariatric surgery at the NMMC Bariatric Center, which has been designated as a Bariatric Surgery Center of Excellence by the American Society for Metabolic and Bariatric Surgery. Each surgery offers improved health and weight loss, and also assists the patient in reaching his/her weight loss goal as long as the proper diet and exercise regimen is followed.

We require the patient to be over the age of 21, generally in good health, and meet the National Institute of Health (NIH) recommendations for bariatric surgery. The NIH recommends bariatric surgery for those individuals with a BMI greater than 40 or a BMI greater than 35 with obesity related co-morbidities and who are not successful in losing weight by other means.

Types of Weight Loss Surgery

Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass results in reliable weight loss with acceptable risks and minimal side
effects if the patient follows post surgery requirements such as diet, vitamin supplementation
and exercise. This operation creates a very small upper stomach pouch (less than one ounce) by
transecting the stomach. Part of the small intestine is cut about 24 inches below the stomach and
is re-connected to the small stomach pouch to provide an outlet to the rest of the intestines. The
lower, larger part of the stomach is bypassed by food but reconnects to the remainder of the small
bowel six feet downstream from the new pouch. Ingested food passes out of the upper pouch
through a small opening into the small intestine. Most of the stomach and the first part of the
small intestine are bypassed by the food. The major objective is to exclude most of the stomach.

The surgery is usually done with laparoscopic instruments through several small incisions. This approach can result in smaller incisions, less pain, quicker recovery, fewer wound complications,
earlier discharge from the hospital and less scarring than the traditional open approach. If for whatever reason, the surgery cannot be safely completed using the small incisions, the abdomen
will be opened, and the surgery will be completed as an open procedure.

Adjustable Gastric Band Surgery

In adjustable gastric band surgery, a specialized silicone gastric band is placed around the upper
part of the stomach and filled with saline on its inner surface. This creates a new, smaller stomach
pouch that can hold only a small amount of food, reducing storage area in the stomach. Like a
wristwatch, the adjustable gastric band is fastened around the upper stomach and then locked
securely in a ring around the stomach.

The band controls the stoma (stomach outlet) by dividing the stomach into two portions: one
small and one larger portion. Because the stomach is divided into smaller parts, most patients feel
full faster. Food is digested normally. The food moves more slowly between the upper and lower
stomach as it is digested. As a result, patients eat less and lose weight. The favorable consequences
are absence of anemia, dumping and malabsorption, while the disadvantages include the need for
strict patient compliance. This procedure recalls the principle of doing the smallest (least invasive)
procedure possible to achieve the desired result. The gastric band is designed to be permanent
and is not meant to be removed.

Vertical Sleeve Gastrectomy

Laparoscopic vertical sleeve gastrectomy generates weight loss by restricting the amount of food that may be consumed without bypassing the stomach or a portion of the small intestine.
A portion of the stomach is removed and a new stomach pouch is formed.

This particular procedure helps to reduce the sensation of hunger by possibly eliminating some of the GI hormones responsible for the hunger pains. The stomach is reduced in volume but functions
normally so most food items can be consumed but only in smaller portions.

What Surgery Will Achieve?

We consider weight loss of more than approximately 30-50 percent of pre-surgery weight a good result. For instance, a person weighing 300 pounds who loses 90 pounds would be considered to have a good weight loss result. We hope and expect approximately 85-90 percent of patients to achieve good to excellent results.

The average patient probably will lose approximately 30-35 percent of the pre-surgery weight, but there is a great deal of variation with some losing more and some losing less. A distinct minority of patients will reach a truly normal weight. In fact, such marked weight loss may not be desirable because of baggy skin and other related problems. Successful weight loss reduces or resolves high blood sugar levels in diabetic patients and decreases or eliminates elevated blood pressure in approximately 90 percent of hypertensive patients. However, these results will depend on individuals and is not guaranteed.

Am I a Candidate for Bariatric Surgery?

Only morbidly obese persons (usually greater than twice the ideal body weight) are considered for surgical treatment. Otherwise, the expected risks may outweigh anticipated benefits. The ideal person should:

Clearly and realistically understand the surgical risks and benefits and how his/her life may change after surgery.

Be able to participate in treatment and commit to long-term follow up.

Be 100 pounds over ideal body weight or have a BMI of 40 or above, or have a BMI of 35 to 40 with associated severe medical conditions (co-morbidities).

Provide evidence of unsuccessful weight loss in non-surgical established weight control programs within the past two years.

Have no contraindications for surgery.

Potential Risks and Complications

Surgery for morbid obesity is considered major surgery. As with all surgeries, bariatric surgery carries the risk of general anesthesia and potential complications that are more common as weight increases.

If you are interested in bariatric surgery to get control of morbid obesity and other health problems, you must first consider the benefits to be gained from surgery versus the risks that you must go through in order to have the surgery. Usually the risks occur right away when the surgery is performed. The benefits take a while to pay you back in the form of improved health, reduced long-term risk of illness and enhancement of your lifestyle.

Risks and complications during either surgery may include perforation of the stomach or intestine, internal bleeding, bowel obstruction. Wound infection (including opening of the wound), incisional hernia, and injury to the spleen with potential removal of the spleen.

Pulmonary embolism (blood clots to your lungs from your legs), pneumonia, atelectasis (collapse of lung tissue), fluid in the chest or other breathing problems may occur. Compression hose and walking after surgery assist in decreasing the incidence of blood clots. With any major surgery, there is the risk of myocardial infarction (heart attack), congestive heart failure, irregular heartbeat, stroke, liver or kidney problems. Although rare (approx. 0.5-1 percent), surgical complications may cause death. Other complications include minor wound or skin infections, urinary tract infection, allergic reaction to medications, excessive vomiting, dehydration, development of loose skin, narrowing or stretching of the anastomosis (outlet of the stomach), peptic ulcer disease, and/or psychological reactions (i.e. depression while adjusting to new eating and lifestyle habits). Other late problems may include failure to lose weight or weight regain.

Roux-en-Y Gastric Bypass surgery achieves weight loss by decreasing intestinal absorption of food and by restricting food intake. Instead of following its usual path, food bypasses a portion of the stomach and small bowel. In addition to surgical complications, some people experience long-term deficiencies of vitamins. Deficiencies reported are B vitamins, A, C, E, K, D, folate and iron. Vitamin deficiencies will be monitored through regular follow-up visits. Ulcers at the site of the stomach or intestinal anastomoses (stomal ulcer) or acid peptic ulcers in the nonfunctional large stomach pouch may occur with Roux-en-Y Gastric Bypass surgery. Stomal ulcers may be caused by smoking, overeating, aspirin or non-steroidal anti-inflammatory drugs (ibuprofen, naproxen, etc.). Cortisone use in the post-surgery period may also lead to a higher incidence of ulcers. Anemia may occur after Gastric Bypass. Close attention must be given to iron deficiency, especially in women of childbearing age. Taking a multivitamin with iron usually prevents this problem. Vitamin B12 supplements may be necessary to prevent anemia.

The benefit of improved confidence and self-esteem may occur; however, some patients experience social or emotional upheavals. Emotional crises such as divorce, acute job dissatisfaction, and other problems can occur as a result of all the changes that occur after these surgeries. Whether these problems are related to the surgeries or weight reduction is unclear, but they have been noted.

Setting Realistic Expectations

The goal of surgery is to help you lose more than half of your excess weight. This can reduce or prevent health problems. It is not cosmetic surgery. Keep in mind that:

Other medically managed weight loss methods must be tried first and documented. Surgery is only an option if other methods have not been successful.

Surgery is meant to be permanent. You will need to make lifestyle changes for the rest of your life.

You must commit to making good food choices and being more active after surgery, otherwise you will not maximize your weight loss.

You will not reach a healthy weight right away. Most of the weight is lost steadily over 12-24 months after surgery.

The surgery is a tool that will help you lose weight. However, by being diligent with exercise and attending support groups and workshops, your chances of losing more weight will dramatically increase.

Having surgery is a personal decision as well as a medical one. Your medical team can teach you about the surgeries and help you measure the benefits versus the risks based on your individual situation. The final decision is up to you. To make it intelligently, you need to know all about the risks and benefits of the surgery.

In order for you to make the right decision, you will be scheduled for several appointments with a variety doctors and/or specialists, a psychologist, a dietitian, and other departments to have lab work and tests done. During these visits, you will be able to ask questions and gain more information about the surgery and recovery period.

Benefits of Surgery

Weight loss is not the only reason that weight loss surgery should be undertaken. The more important benefits of surgical treatment are the improvements of general health and quality of life. The following medical conditions are normally improved or eliminated after weight loss:

Now that the Bariatric Center is designated as an Accredited Center by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program and is recognized in the Optum Centers of Excellence Network, weight loss surgery at NMMC is covered by more health plans, including those for teachers, state employees and many offered by employers, check your health plan benefits, talk to your doctor and weigh your options.